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Two studies published in the past month lend support to the notion that autism looks different in girls than it does in boys, making it harder to recognize and diagnose in girls. The studies reflect growing suspicion in the research community that the underlying biology and the experiences of girls with autism may both be distinct.

The first study, published in the March issue of the Journal of the American Academy of Child and Adolescent Psychiatry, is the largest yet to try to parse the differences between boys and girls with the disorder1.

The researchers report that autism characteristics in girls depend on their level of intelligence. “On the lower end, they tend to have more social communication impairment and lower cognitive ability” than boys who have the disorder, says study leader Thomas Frazier, director of the Center for Autism at the Cleveland Clinic in Ohio. “On the higher end, they have fewer restricted interests.”

These differences may make it tricky for parents, teachers and doctors to recognize the signs of autism in girls. This is especially true because autism has traditionally been thought of as a boy problem: Four times as many boys as girls are diagnosed with the disorder.

“For a long time the gender disparity has been talked about as if it’s a fact,” says Jane McGillivray, associate professor of psychology at Deakin University in Victoria, Australia. McGillivray led the second study, a pilot effort to investigate friendship skills in girls and boys with high-functioning autism, published 28 February in Molecular Autism2.

Researchers are now beginning to question the degree to which this gender disparity is real.

Defining gender differences in the symptoms of autism may help researchers nail down how much each of these possibilities contributes to the skewed diagnostic ratio.

High and low:

The first study draws on information from 304 girls and 2,114 boys with autism enrolled in the Simons Simplex Collection (SSC), a database of individuals with autism and their unaffected parents and siblings. (The SSC is funded by the Simons Foundation, SFARI.org’s parent organization.)

Some of the findings echo those of previous studies of gender differences in autism, but this study is substantially larger, adding heft to the results.

Among individuals with autism who have an intelligence quotient (IQ) lower than 70, girls have greater social communication impairments than do boys, the researchers found. Girls in this group also have lower IQs on average than the boys do.

Those findings are consistent with previous studies showing that females diagnosed with autism tend to be more severely affected than males. They are also in line with the hypothesis that more mutations are required to produce autism in females. “Females may require extra hits, but once they get those extra hits they become severely affected,” Frazier says.

Curiously, the researchers also found that regardless of IQ, girls with autism show more irritability and externalizing behaviors than boys who have the disorder. That’s a surprise because externalizing behavior — that is, acting out — is typically thought of as a boy-like behavior.

Finally, for individuals with IQs above 70, the most striking difference between girls and boys with autism is a lower prevalence of restricted interests among girls.

Some researchers say this last finding doesn’t jibe with clinical experience. “They do have restricted interests, but their restricted interests are more socially appropriate,” says David Skuse, professor of behavioral and brain sciences at University College London, who was not involved in either study.

For example, a 10-year-old girl with autism might bombard a listener with facts about her favorite pop star whereas a boy might rattle off train timetables, and a teen girl with the disorder might obsessively collect makeup rather than old coins. Clinicians may be more alert to certain stereotypical restricted interests, such as trains, than they are to female topics.

“The problem is that the way we have defined autism, conventionally, is a male stereotype,” Skuse says.

Frazier says that because the analysis found a large difference in the level of restricted interests between boys and girls, this gender difference is probably real. In addition, he notes that highly trained clinicians evaluated individuals enrolled in the SSC and would have picked up on restricted interests even in the girls.

Still, it’s possible that the clinicians missed some subtle symptoms, Frazier says. The girls’ “restricted interests may just be more female-specific presentations that we’re not picking up in the data.”

The results suggest that clinicians need to be extra diligent about looking for restricted interests in girls, Frazier says. Otherwise, high-functioning girls might be labeled as having social communication disorder — a new diagnostic category that involves social impairments but not the restricted interests and repetitive behaviors characteristic of autism.

It may also be easy to misdiagnose girls with low IQ as having intellectual disability alone. In both cases, these girls would miss out on behavioral interventions that could improve their social deficits.

Female prism:

The second study also suggests that autism can be subtle and difficult to identify in girls. McGillivray and her colleagues administered the Friendship Questionnaire to 25 girls and 25 boys with autism, all aged 10 to 16 years. This questionnaire contains 35 multiple-choice questions to assess an individual’s understanding of friendship and the quality of his or her social relationships3.

Not surprisingly, the researchers found that individuals with autism score lower on the Friendship Questionnaire than controls do.

Within the control group, boys score lower than girls do — consistent with the general sense that girls have better social skills. Among those with autism, too, scores differ by gender: Girls with autism have higher scores than boys with the disorder, but their scores are lower than those of girls in the control group.

“The interesting bit is that females with autism were similar to the typically developing males,” says McGillivray.

Together, Frazier says, the two new studies suggest that “maybe we need sex-specific norms for some of the instruments we use.” Instead of evaluating girls’ restricted interests or social skills on an absolute scale, he says, researchers should compare their scores with those of unaffected girls of the same age.

It’s possible that girls with subtle social deficits aren’t diagnosed with autism because they don’t actually have autism. Yet many clinicians insist that many of these girls have the disorder, though they have trouble explaining why. Conversation with these girls “just has that quality of not quite meshing,” McGillivray says. “It is very difficult to specify.”

Experts say that in order to understand gender differences in autism — and to improve diagnosis for girls — they will need to better define what is abnormal about these girls’ behavior.

As a step in that direction, Frazier plans to look for questions about restricted interests and repetitive behavior on autism tests that garner similar answers for girls and boys. That subset of questions may do a better job of picking up the behaviors in girls, he says.

Researchers may also need to design studies that include girls with subtle social difficulties who are not diagnosed with autism. That’s because the field currently has a chicken-and-egg problem: trying to characterize autism in girls by studying girls diagnosed according to boy-centric criteria.

“When you’re looking at the female phenotype, if you look at it through the male prism you’ll only see the male characteristics of autism,” Skuse says. “You only see what you expect to see.”

When my son aged 14 was diagnosed a year ago with aspergers I began to read as much as possible on the subject. As I became aware of the c traits I could see them clearly running through my family. At first it was most noticeable in the males, but I began to see traits in the females too. My mother, daughters and myself. I firmly believe this is not a diaper more prevalent in males but that it is just harder to spot in females. Mainly because they seem better at identifying and then compensating for their social difficulties. However what I have observed is that the traits become most pronounced when these females are under pressure. Anxiety attacks, depression, emotional breakdown and social withdrawal result. I agree females are much less likely to have unusual social interests, they are most definitely there though. I also believe that although women and girls can appear to cope better than males, they continual exertion required to cope with social situations leave women exhausted. At high school I began to develop migraine . I got a migraine every Friday. When ever I engage in demanding social situations, I am exhausted afterwards.
I believe the most helpful diagnostic criteria for females should Centre on literal thinking, sensory issues and not so much how they cannot grasp social situations, but how much effort is required to manage social situations that a neurotypical would take for granted.

I agree. It is strange that they seem to only focus on repetitive behaviors and restricted interests, and not include the sensory issues, how extremely stressful social situations can be, and how difficult it can be for us to struggle with daily tasks, memory, etc. Girls are so at risk for eating disorders, depression, and severe anxiety. I am a mature woman, very high-functioning, and still struggle every day even though I finally “understand” myself. My coping skills are great but I’ve worked on them all my life. I teach many girls who I recognize as being just like me. I hope better for them so that they can–not be fixed or cured–but know that they are okay as they are. Hopefully society will learn to accept them–us–too.

“I believe the most helpful diagnostic criteria for females should Centre on literal thinking, sensory issues and not so much how they cannot grasp social situations, but how much effort is required to manage social situations that a neurotypical would take for granted.”

This. I think this is the key to figuring out which women are aspies. I know I’m constantly being told I say the wrong things (more so when I’m overwhelmed or tired) and take things too literally, but can’t possibly be an aspie since I catch sarcasm (the language of my family) and cry. Why do they think aspies don’t experience emotions? Anyhow, it’s difficult to manage most social situations for me, but I do well enough. Enough to be called quirky. I think using this information as criteria for diagnosis is important.

And I don’t have typical limited interests of women. I study nutrition and have tried almost all the crafts, settling on sewing and illustration (design). I am a design, craft and nutrition geek. 🙂 I also play with spreadsheets for fun. The more complex the calculations I can muster between the cell relationships, the more interested (and tuned out) I am.

I suspect I am undiagnosed and on the autism spectrum. I had a speech disorder as a child and still people assume I have an accent they can’t quite identify. I have always had a very limited number of people I consider friends but their sex, age, sexuality, gender identity, or race didn’t matter to me. I am nearly asexual. I have never been at ease with small talk, but if a conversation opens up on one of my pet interests, I talk too much. I don’t have a clear idea of what expected behavior, fashion, or speech is in many situations, but I pass for just normal enough people call me unique rather than disordered. I have *extreme* sensory sensitivity. Bright light, loud noises, the wrong textures or pressure of touch, are excruciating. Sometimes, I can smell products in sealed packaging as if they were open under my nose, and cannot stand to walk through a store because of the nauseating combination of odors. I have anxiety issues, and I lock my feet or jiggle my legs, rock, and scratch my scalp at various levels of stress.
One day I should really see a doctor about it– but I have other, life=threatening issues and I have trouble talking to most doctors. They are often suspicious or dismissive of me and my education, and yet unless I walk in with a potential self-diagnosis, they never know what to make of me because I present a-typically. For instance, I went to see the doctor about a problem with a broken bone I hadn’t been able to tell was broken until the swelling went down enough for me to sense movement. She assumed I had bursitis, which would not explain the sense of movement, but sent me for an X-ray anyhow. And they found out I indeed had a broken bone, but that my self treatment (for what I assumed was soft tissue damage) was working out to heal it faster than immobilizing it would have.

Autism is defined by something more intimate than restricted interests, repetitive behaviors or even social skills. Theory of mind is the concept that is weak or missing. Study that. Also, not scoring well on an IQ test and communication impairments go together. I wonder if they assessed intelligence with the Ravens scale, which measures people who think in pictures, which many autistic people do.

The above comment about looking for a low IQ test score is totally innaccurate and misleading. Many people with a diagnosis of ASD score either averege or above average in IQ tests. Life is hard enough for people on the spectrum. Please dont add to this burden by perpetuating negative stereotypes that have no basis in reality

Some of us have been saying this for years, I can remember telling prof. Mike Rutter at a conference, that I believed the ratio was wrong. “But the research statistics say otherwise” he insisted. I said “What if the research is concentrating mainly on boys because autism is underdiagnosed in girls” then of course the ration would be an artefact of selection bias. He was not having it, but I bet he is thinking again now, at least he ought to be.

For me, I believe a special interest has been studying human relationships and trying to fit in. I couldn’t understand why I was having so much trouble and spent decades studying human social behaviour to be able to fit in. If I don’t know something, I go and study about it. I think quite a few autistic women do this and probably a few men.

I agree. In my twenties, I went to a psychiatrist for depression and also because I was having problems finishing my studies, my psychiatrist then sent me to a psychologist and to a neurologist. Even though my EEG was normal, my psychiatrist and my psychologist gave me a diagnosis of Asperger’s Syndrome. Both were surprised because they did not understand how could I go undetected for so many years, my mom does not believe my diagnosis and she told me “all is in your head” and I can understand her because I never told anyone about my problems until I went to a psychiatrist. I was always very quiet since I was little and I cried all the time for anything. I never played with other children because I could not understand them. Now that I’m an adult and after my diagnosis, I can understand many things from my past, somehow I’m in peace with myself now.

When I recently told my mother, she immediately told me that I never presented with autistic characteristics, “but that if it makes you feel better, and it helps you to correspond and communicate with others, it is good.”
I then sent her info on the different ways girls and boys present, but haven’t heard from her yet. I might be boring the hell out of her, probably.
I, too, am at peace with myself, but fortunately that started happening 8 months before the realization that I have Aspergers. This diagnosis was just a clincher, and explained my life’s struggles perfectly.
I feel grateful.
I love being me.
I love being an Aspiegirl.
I have others who love me.
What more does one need?
Acceptance is Happiness!

I have identical twin girls who are Autistic. When I had to fill out a form to describe how one of my daughters would react to situations I started to cry because I was describing myself. Teachers from the girls special school came to our house with the class and they observed that I had autistic tendencies. I don’t know what they were.I thought I had successfully hidden my stress and anxiety from the world for 50 years.

I think it’s a bit silly to make a distinction between “male” and “female” interests in the first place and realize that it can also be healthy for women to take interest in more traditionally “male” subjects such as science and technology and that doesn’t always mean that they have a disorder. In making a diagnosis they should always be aware of the underlying pattern rather than the actual interest and keep in mind that interests may differ for each individual, so (e.g.) whether a female is obsessively talking about computers or fashion should not matter, because the pattern is the same. Indeed, it probably is more obvious in the first case, especially when society is more geared toward male/female stereotyping [so “masculine” interests for women stand out]. And besides, narrow interests is but 1 clue, it doesn’t count for every individual with an ASD; they may have a range of interests, just as typical people do.

I also think it’s ridiculous that some use low IQ as a key marker for an ASD. I know many people with an ASD who have average or above average to high intelligence and I am probably one of those; I have been said to have an ASD & study engineering at university (yes as a female, my interests have never been feminine although recently I have developed somewhat an interest in dressing more stylish).

How ASDs can go undetected? Well, you can learn coping mechanisms, especially if you have above average intelligence. You can use intellect to learn acceptable social behavior through pattern recognition and memory and asking people in your environment for feedback on your performance, which you can use to “adjust” your behavior. This could also be part of the reason why it might be easier to find children with an ASD [they did not learn those mechanisms yet] than adults. & Yes indeed, because you have to (subconsciously) assess situations all the time and react appropriately, that costs more energy compared to intuitively knowing how to act or what to say, so you may feel tired after lots of socializing or group project work.

And group work can get very frustrating if some people have issues with your behavior, no one tells you and you don’t [seem to be able] to pick that up so you have to find out in an awkward way. As I can tell from experience. Fortunately that doesn’t happen all too often and a developed ability for pattern recognition can come in quite handy. 🙂

You have valid points. It is not so cut and dried as they want to make it seem. When one looks more at the issues causing problems, one finds that there are definite patterns. Even though some might be subtle.

Hello, I am certain that I am at the High Functioning end of the autistic spectrum. And the thing with finding patterns in things. I cannot “read” people at all, and will ask my husband ‘What are you thinking?’in a way that would annoy most people. I try to read the sequence of things, and whole body language. It is all very analysing – and tiring!! I think that the very harsh social pressure on girls contributes to both anxiety and depression and our willingness to find coping mechanisms to appear “normal”. I have a strangely long delay between an event that is upsetting and the corresponding emotional reaction to it. Do any of you feel like this? And when it arrives it is a huge horrible mess that can be barely controlled. . . cue for comments of a derogatory nature. . . I have been subjected to them all in the past (You are: weird; paranoid; controlling; silly; making a fuss etc.) But those feelings are valid and real, even if they do take a week or month or longer to arrive fully processed.
I have a child who was diagnosed at the age of eight. I am so like him and just know the kind of things to avoid, like lots of noise in an unfamiliar place, because I hate it too. Being a woman is hard to be if you look all “female” but don’t behave in a typical female way. I scored 43 on the AQ test and am hoping to go see my GP for a referral for diagnosis. Another Lady above talked about finding peace with themselves. That is what I want too. To replace a wrong idea wrongfully imposed on me about who I am; and know fully what is real. I really wish the path to formal diagnosis didn’t involve approaching a GP. I think that screening sessions should be periodically offered at doctor’s surgeries so that we don’t have to be afraid of getting it wrong. After a lifetime of humilation around other people I can see it takes a huge amount of courage to seek a formal diagnosis. I feel that I must do this because it is the only way to get the medical profession to really take notice and see that it is not a “mainly boys” condition. You are all so brave Ladies, so very very brave indeed.

You may or may not fit the criteria for diagnosis, but seeking an official diagnosis for anything shouldn’t be necessary to find relief in being who you are. Diagnoses provided by the medical profession simply exist for categorizing people, which helps others know how they are expected to treat you so you will be more responsive. Remember above anything, you are human, and everyone has a unique personality, and you should be proud of that.

I had been diagnosed with severe ADD,but there were several things about this diagnosis that did not explain my difficulty coping with life. My twin’s son was diagnosed in the spectrum, I realized I was just like him as a child in many ways with sensory problems. I cried everyday I came home from school until 10th grade (even when I had ADD therapy which did help me a teeny), I know now those with sensory issues feel this way, so frustrated & overwhelmed all the time that it is difficult to cope. I did not socially integrate or really have friends, it was impossible, I had a 3-ring circus going on in my head, deeply thinking & absorbing, but looking like low intelligence on the outside. In reality, I am gifted, in some intellgence areas in the top 2%. I never enjoyed recess, lunch, or music or any of this because it was too overwhelming. I could not take showers without screaming because of the pain, this caused a lot of anxiety because people thought I was being ridculous due to things like this. I suffered from low self esteem, as many times I was misunderstood. I still don’t get sarcasm, and can’t read people well, I say things that are not necessarily socially appropriate, especially in group settings. I do better one on one, it’s easier to focus, but even then I can obsess on topics. I have a very vivid memory and am very inquisitive, but it’s not very socially acceptable to be so deeply interested in everything. I was tested in college and the psychologist could not believe how I was able to cope because my brain missed a lot of stimuli. I do believe I may be in the spectrum, my twin is. He was misunderstood his whole life, ex. incapable of not speaking in straight tones, feeling emotion but instead of comforting people irritating them because he speaks in the wrong tone, or hammers them with advice, unable to see that is not what they need, but being hurt that he hurts people not knowing why. I would like to get tested again. I am not sure if I am in the spectrum or just bad sensory issues, I have balance,reflex,visual perception(prioception),hearing,touch severe sensitivity issues. But I CAN feel the pain of people that are diagnosed with aspergers because I feel I am the same way. But I cannot know if I am truly in the spectrum without a test?

I agree with Emma “believe the most helpful diagnostic criteria for females should Centre on literal thinking, sensory issues and not so much how they cannot grasp social situations, but how much effort is required to manage social situations that a neurotypical would take for granted.”

I hope they come up with better testing for girls. I’m 26 and have gone undiagnosed all my life. I’ve been reading more about autism/aspergers and i finally understand why it has been so difficult for me to relate to other females and to just function “normally” on a day to day basis. All my life I’ve been called weird or a freak because I don’t behave according to the rules society has set up as “normal” for girls. Now that i’ve read about it I can finally sort of breathe and say okay this is why, this makes sense. This is why I am the way I am. My supervisor called me weird yesterday and it hurt because people who don’t live with autism have no idea how hard it is for those of us who do, they don’t get that every second of every day is spent trying to fit in and not just curl into a little ball because every sight and sound is hightened and not only are we focusing on those things and where they’re coming from but we’re also trying to converse and interact with people and its very tiring. I apologize for the rant and thank you for reading.

My daughter is 8 yeas old and has been diagnosed with high functioning autism. The doctor has signed off on the diagnosis and is troubled by giving it to her. She has some learning disability issues and has some social issues. My whole issue right now is getting the right treatment. If girls show differently than boys, then shouldn’t the treatment be different.

I think getting a diagnosis is a good thing. Someone above talked about being labelled by the medical profession… Well we all carry labels and they are often subject to the mood of the people who surround us. Being ‘Weird’ is the least unpleasant. I think that a label that forces those same people to take me seriously as an autistic person would be better than all the others. It is time to stop expecting people to ‘understand’; they don’t; and to ask for accomodation for our eccentric personalitites – the social motivated person does not tolerate the one who ‘chooses’ to be different.
What I am saying is I DO NOT HAVE A CHOICE TO BE THIS WAY. a diagnostic label may not address all the issues that a person is faced with in this society, but it is a means to start understanding each other: I am not being ‘antisocial’ – I am just really bad at socialising; I am not being ‘aggressive’ – I am speaking directly without using feminine social language; I am not being ‘aloof’ – I am watching carefully so I don’t make an embarrassing mistake in a group; I am not ‘unfeeling’ – I find it difficult to know how I feel until later, when I have had time to process all the ‘data’ from the encounter with other people.
The problem I believe exists on both sides: if Autistic people won’t go and get a diagnosis how do you expect those ‘Normal’ people to understand what your issues are? We are often guilty of trying to punish the rest of the world for the cruelty and intolerance of some of the people we have met in our lives. There are so many who do care, are open, interested, and fascinated by the unusual world view that the Autistic Self inhabits. The Label is just that…. a Label, and when you start to tell someone about your unique experience THEN they can begin to understand what that label means to you.

I have been searching for an answer for my 13 year old daughter for the last 3 years. She has recently been diagnosed with social communication disorder, however, I feel it is more than that. I read Beni’s comment above and is sounded exactly like my daughter. She has always struggled socially but now it’s combined with being a teenager. She is very thin and controlling of her food so we are working very hard on her not developing an eating disorder. She has issues with OCD as while as stimming – which she only does at home – never at school. She suffers from depression and anxiety. She scored at the high end of the IQ test. She is in extension classes as well as the gifted and talented program. She is smart, athletic, tall and beautiful but sad, anxious, awkward and unhappy all at the same time. She is seeing a developmental pediatrician, psychiatrist and psychologist but no one is willing to say autism/Asperger’s which is what I believe she has. It’s all very frustrating.

I really appreciate reading all of this. A friend of mine actually told me that autism presents differently in women and that my “quirks” make her think of autism. The thing is I had never really thought of that because I have relatives with it but they’re all male on the severe end and have all the delayed speech and other typical indicators of autism. But the more I’ve looked into the female symptoms the more I honestly see myself in the complete struggle of communicating the way my peers communicate. I find myself so extremely frustrated sometimes when people have taken of fence to my bluntness and I just could not get them to understand why it wasn’t personal at all. I find I am overly conscious of how I explain things but monitor myself. I often fall into an almost monotone esoecially when I’m tired or otherwise just don’t feel like putting in the extra effort of making my expression match the interaction. Idk autism runs in my family but I only have male relatives with official diagnosis so it just never occurred to me to consider it. But it would explain why social interactions can be such a chore for me.